Imperial Ballroom

13. The Surgical Implication of Broncholithiasis

L. PENFIELD FABER, ROBERT J. JENSIK, SURRENDRA K CHAWLA*,

C. FREDERICK KITTLE, Chicago, Illinois

A calcified hilar or mediastinal lymph node can compress or erode an intra-thoracic structure causing significant symptoms including severe hemoptysis. We have operated upon 31 patients with bronchohthiasis. The great majority of these complained of cough and 15 of 31 had hemoptysis. Only one patient had Iithop-tysis. Distal atelettasis and bronchiectasis were common pathologic changes

Surgical measures carried out were- segmental resection - 15; lobectomy - 5, bilobectomy - 1; pneumonectomy - 1, removal of nodes only - 2; repair of broncho-esophageal fistula - 4; bronchoplastic procedures - 3.

Granulomatous reaction may simulate carcinoma and bronchoscopy, bronchial brushing, and bronchography are of extreme importance in pre-operative evaluation. The presence of calcined nodes revealed by tomography may be the best clue to the diagnosis.

Broncholithiasis, with its increasing frequency, must be recognized. The great variety of pathological alterations which one may encounter requires a versatile surgical approach.

*By invitation

14. Pulmonary Hyperinflation: A Form of Barotrauma During Mechanical Ventilation

OSCAR R. BAEZA*, ROBERT B. WAGNER*

and BRIAN D. LOWERY*, Baltimore, Maryland

Sponsored by Vincent L. Gott, Baltimore, Maryland

The term "barotrauma" has been used to describe several specific complications related to mechanical ventilation. These include tension lung cyst, pneumothorax, pneumomediastinum, pneumoperitoneum and subcutaneous emphysema. Pulmonary hyperinflation is another complication of mechanical ventilation, currently unemphasized, that we describe in five patients, being fatal in three. Serial radiographs and blood gas data demonstrate the progression and clearing of pulmonary infiltrates and contusions with the associated hypoxemia and hypercarbia. Two pathophysiologic mechanisms are discussed. The simpler, and well recognized, "ball-valve" airway obstruction allows inspiration of air delivered by the mechanical ventilator but prevents expiration. A more complex circumstance exists when pulmonary contusion or infiltration produces differential lung compliances. This latter was seen to allow extreme hyperinflation of areas of normal lung while attempting to ventilate abnormal lung of low compliance. This mechanism is particularly evident when positive end expiratory pressure (PEEP) is used in an attempt to open collapsed ventilatory units. Functional complications of lung hyperinflation include decreased alveolar ventilation and compression effects on adjacent structures. Interference with and shifts of regional lung perfusion may worsen gas exchange. Initial symptoms are restlessness and intolerance of the ventilator. If uncorrected, agitation, cyanosis, hypoxemia and hypercarbia supervene. Prolonged expiration is evident. Eventually, circulatory collapse occurs. A successful outcome was seen with early recognition and proper treatment, including airway clearance by bronchoscopy, the judicious use of bronchodilators and the discontinuance of PEEP.

*By invitation

15. Primary Tracheal Anastomosis Following Resection of the Cricoid Cartilage with Preservation of Recurrent Laryngeal Nerves

F. G. PEARSON, J. D. COOPER*, J. M. NELEMS* and

A. W. P. VAN NOSTRAND*, Toronto, Canada

Resections at cricoid level pose the problems of recurrent laryngeal nerve damage and loss of circumferential cartilaginous support. Strictures within the cricoid ring have usually been managed with keels or stents, and neoplasms by laryngectomy. This paper reports on six patients with lesions involving cricoid, who were successfully managed by segmental trachea! resection and removal of all but a thin shell of posterior cricoid plate. Distal trachea was anastomosed at subglottic level within 1 cm. or less of the vocal cords.

Two patients had traumatic transection at crico-tracheal level with disruption of cricoid cartilage and avulsion of both recurrent nerves. Each was managed by resection of all cricoid cartilage lying below the inferior margin of thyroid cartilage, and anastomosis of distal trachea to inferior thyroid margin. No attempt was made to reconstruct the avulsed nerves.

Four patients with tracheal lesions involving cricoid (two post-intubation strictures, one chemical burn, one adenoid cystic carcinoma) - and intact recurrent nerves were managed by segmental tracheal resection with complete removal of the anterior cricoid arch and that part of the postenor cricoid plate lying subjacent the mucosa. A thin posterior shell of cricoid plate was preserved which included crico-thyroid joints and recurrent nerves. Cartilage at the distal tracheal resection line was fashioned to form a complete ring and anacstomosed to mucous membrane at subglottic level within 1 cm. or less of the vocal cords.

Primary healing and good clinical results were obtained in all six patients. In the four patients with intact recurrent nerves, nerve function was preserved. This technique provides a method for resection and reconstruction in one stage for selected lesions at cricoid level.

*By invitation

16. Esophagogastrostomy - Analysis of 55 Cases

ARTHUR D. BO YD, RAMON CUKINGNAN*, RICHARD M. ENGELMAN*,

S. ARTHUR LOCALIO*, LOUIS SLATTERY*, DAVID A. T1CE, and

FRANK C. SPENCER, New York, New York

Esophagogastrostomy was performed in 55 patients following esophagectomy for malignant disease of the esophagus or esophagogastric junction at the NYU Medical Center from 1969 through 1973. In 29 (53%) of these patients a Nissen type fundoplication was incorporated into the operative procedure (Group I) while in 26 (47%) fundoplication was not utilized (Group II). The operative mortality was 10% in Group I and 8% in Group II. Postoperative barium esophagograms demonstrated reflux in 3 of 18 patients (17%) from Group I and in 9 of 16 patients (56%) from Group II. Clinical evidence of reflux was seen in 2 patients from Group I and 5 patients from Group II. An anastomotic leak occurred in 1 patient (Group I). Five patients in Group I developed early dysphagia from the fundoplication which responded readily to dilation. The survival at one year was 45% in Group I, 42% in Group II and at 2 years was 28% in Group I and 30% in Group II.

These data show that a Nissen fundoplication does not increase operative mortality or morbidity and significantly reduces the frequency of esophageal reflux. We favor its routine use with esophagogastrostomy.

INTERMISSION - VISIT EXHIBITS (Albert Hall)

*By invitation

17. Columnar Lined Lower Esophagus: An Acquired Lesion with Malignant Predisposition

A. P. NAEF*, M. SAVARY*, and L. OZZELLO*, Yverdon, Switzerland

Sponsored by F. G. Pearson, Toronto, Canada

This paper reports observation on 126 patients with columnar epithelium lining the distal esophagus. The underlying pathology was evaluated by history and esopnagoscopy, and many of these patients underwent repeated endoscopic examination to clarify the pathogenesis of the lesion. Changes in esophageal epithelium were documented by direct biopsy and photography.

In most cases, history and endoscopic documentation demonstrated that the abnormality was due to gastro-esophageal reflux and ulcerative esophagitis. In some patients with esophagitis, areas of mucosal ulceration were found to be replaced by columnar epithelium at a subsequent esophagoscopy. These observations indicate that "columnar lined lower esophagus" can be an acquired condition which results from the replacement of ulcerated squamous epithelium by columnar epithelium during the healing phase of esophagitis.

Twelve of the 126 patients in this series had an adenocarcinoma in the distal esophagus. In three of these patients the malignancy was confined to the segment of distal esophagus lined with columnar epithelium. In nine others the tumour, although located on the distal columnar lined esophagus, extended down to the cardia inclusive. It has been claimed by others that peptic esophagitis is associated with an abnormally high incidence of adenocarcinoma in the distal esophagus, and our observations support these claims. We speculate that metaplastic changes are associated with columnar re-epithelialization of ulcerated areas during repeated exacerbations and remissions of esophagitis, and predispose to malignant transformation.

Columnar lined lower esophagus is an acquired condition secondary to gastro-esophageal reflux and ulcerative esophagitis in most cases. The incidence of esophageal carcinoma is high in such patients and warrants critical endoscopic assessment and biopsy of all suspicious areas.

*By invitation

18. Substernal Gastric Bypass of the Excluded Thoracic Esophagus for Palliation of Esophageal Carcinoma

MARK B. ORRINGER* and HERBERT E. SLOAN, Ann Arbor, Michigan

Curative resectional therapy for esophageal carcinoma is not possible in the presence of involved celiac or cervical lymph nodes or a tracheoesophageal fistula. In these situations, relief from dysphagia and repeated aspiration may be accomplished by means of a substernal gastric bypass of the excluded thoracic esophagus. This procedure, performed through a cervical and upper abdominal incision, involves mobilization of the stomach to a substernal location with anastomosis of the gastric fundus to the cervical esophagus. Exclusion of the thoracic esophagus at either end is accomplished with the surgical stapler. Five patients, two with malignant tracheoesophageal fistulae, and three with carcinoma of the esophagus and either celiac or cervical lymph node metastases have been palliated with this procedure. Of these patients, two died with massive exsanguination from aorto-tracheo-esophageal fistulae 2 months and 9 months after operation, one died of progressive cachexia after 2 months and two are alive 3 months and 6 months after surgery. All patients have been able to eat regular diets postoperatively.

This technique of esophageal bypass avoids the need for a thoracotomy and mediastinal dissection; it requires only a single, cervical gastrointestinal anastomosis; and it utilizes the stomach, which possesses a dual blood supply that surpasses that of any other portion of the gastrointestinal tract used for esophageal replacement. The technique possesses advantages over more conventional palliative operations which combine the hazards of a combined thoraco-abdominal operation with multiple intestinal anastomoses in a generally debilitated incurable patient.

11:15 A.M. Address of Honored Speaker

SURGERY IN THE SUB-ARCTIC:

A THORACIC SURGEON'S ODYSSEY

Gordon W. Thomas, Director

International Grenfell Association

St. Anthony, Newfoundland

*By invitation